The latest move is a law that enables trained physician assistants, also known as physician associates, to perform first-trimester abortions without a supervising physician present. The measure, which passed last year and took effect Jan. 1, also lets PAs who have been disciplined or convicted solely for performing an abortion in a state where the practice is restricted apply for a license in California.

Physician assistants are now on par with nurse practitioners and certified nurse midwives trained in abortion care, who in 2022 won the ability to perform abortions without a doctor present.

The need for more abortion care practitioners is being driven by efforts in many states to gut abortion rights following the Supreme Court’s 2022 decision ending constitutional protection for the procedure. have implemented abortion restrictions that range from cutting federal funding for abortion coverage to outright bans, according to the Guttmacher Institute, a research organization concerned with reproductive health.

With the new law, “there will be fewer barriers, and shorter wait times for this essential service,” said Jeremy Meis, president-elect of the California Academy of Physician Associates. While it is unclear how many of California’s 16,000 PAs will be trained in performing abortions, that PAs are more likely than physicians to practice in rural areas where access to abortion is limited. More than in California lack clinics that provide abortion.

Comparing data from the first six months of 2020 with the same period in 2023, the number of abortions jumped from a 20% increase as the state became a refuge for women seeking abortions. California has passed a suite of to build in protections and increase access, and a dozen other states, including Oregon, Minnesota, and New York, have mounted similar efforts. Seventeen states, including California, now allow PAs to perform first-trimester abortions, according to the American Academy of Physician Associates.

There was little opposition to the new California law, with two physicians’ groups supporting it. But the American Medical Association, the country’s most powerful doctors’ lobby, has fought vigorously against what it calls “” — that is, changes that allow clinicians like PAs to do medical procedures independent of physicians.

“Our policy stance is the same on scope of practice expansion regardless of procedure,” noted Kelly Jakubek, the AMA’s media relations manager. The AMA’s website points to legislative victories in 2023, including striking down “legislation allowing physician assistants to practice independently without physician oversight,” in states including Arizona and New York. The AMA did not take a formal position on the California legislation. Its local chapter, the California Medical Association, took a neutral position on the legislation.

In preparation for the new law, one physician assistant at Planned Parenthood Pasadena & San Gabriel Valley began learning how to perform aspiration abortions — a procedure also known as dilation and curettage that uses gentle suction to end a pregnancy — at the end of last year. The PA, who requested anonymity due to concerns about safety, said that with abortion restrictions in place around the country, “I just think it’s really important to be able to provide a comfortable, safe, and very effective way to terminate a pregnancy for patients.”

She is now one of six PAs and midwives at her clinic who can offer aspiration abortions. To reach competency, she participated in 50 procedures and learned how to administer medication that eases pain and anxiety. Such , as it is known, is frequently used for first-trimester abortions. Now she, like any other advanced practice clinician who has obtained skills in performing abortions, can train her peers — another feature of the new law.

The length of time for training and the number of procedures to reach competency varies based on a practitioner’s previous experience.

“It’s encouraging this cross-profession training and collaborations, which is really important when we’re looking at increasing access to essential services,” said Jessica Dieseldorff, senior program manager of abortion services at Planned Parenthood Mar Monte in Santa Cruz.

In December, California committed $18 million to help accelerate training in abortion and reproductive care for practitioners, including PAs, through the Reproductive Health Care Access Initiative.

Dieseldorff, a nurse practitioner who trains other advanced-practice clinicians in abortion care, said that rural communities, in particular, will reap the benefits since many rely solely on physician assistants and other allied clinicians.

Reflecting on her career, she said much has changed since she became a nurse 25 years ago. At that time, she worked only as support staff to doctors providing abortions.

“When I began, did not exist in this country,” she said, referring to the practice of using two drugs often prescribed to induce abortions. “It’s been gratifying to be able to progress and become a provider myself, provide non-stigmatizing and compassionate and safe care to patients; and now, at this stage in my career to be training others to do the same.”

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Her commitment to becoming a maternal health care provider was sparked early on when she witnessed the discrimination and judgment leveled against her older sister, who became a mother as a teen. When the Supreme Court overturned Roe v. Wade in 2022, Peacock was already in her residency program in California, and her thoughts turned back to women like her sister.

“I knew that the people — my people, my community back home — was going to be affected in a dramatic way, because they’re in the South and because they’re Black,” she said.

But even though Peacock attended the Medical College of Georgia, she’s doing her obstetrics and gynecology residency at the University of California-San Francisco, where she has gotten comprehensive training in abortion care.

“I knew as a trainee that’s what I needed,” said Peacock, who plans to return to her home state after her residency.

Ever since the Supreme Court decision, California has worked to become a sanctuary for people from states where abortion is restricted. In doing so, it joins 14 other states, including Colorado, New Mexico, and Massachusetts. Now, it’s addressing the fraught issue of abortion training for medical residents, which most doctors believe is crucial to comprehensive OB-GYN training.

A law makes it easier for out-of-state trainees to get up to 90 days of in-person training under the supervision of a California-licensed doctor. The law eliminated the requirement for a training license and also permitted training at programs such as Planned Parenthood that are affiliated with accredited medical schools.

“By allowing physician residents to come to California, where there are more opportunities for abortion training, and by allowing them to be reimbursed for this work, we’re sending a message that abortion care is health care and an essential part of physician training,” said Lisa Folberg, CEO of the California Academy of Family Physicians, which supported the bill.

The question of how to provide complete OB-GYN training promises to become more urgent as the effects of abortion bans on medical education become clear: restrict or ban abortion to the point of effectively stripping 20% of OB-GYN medical residents of the opportunity to get abortion training, according to the in Abortion and Family Planning. That’s 1,354 residents this year out of 5,962 OB-GYN residents nationwide.

The restrictions in some cases aim to reach beyond state borders, spooking medical students and residents who fear hostility from anti-abortion groups and right-wing legislators.

One OB-GYN resident in a state with abortion restrictions, who asked to remain anonymous for fear of reprisals, said she’s keen on getting comprehensive abortion care training in California — but can’t.

“My program will not allow us to perform abortions in other states,” she said.

She said administrators worry that doing so would subject residents to litigation because the program is state-funded.

“That is how my program is interpreting the law,” she said. “They’re being very conservative in order to protect us.”

Pamela Merritt, executive director of , pointed to a Kansas law that requires repayment of state medical school scholarships — with 15% interest — if residents perform abortions or work in clinics that perform them, except in cases of rape, incest, or a medical emergency.

Doctors point out that abortion training is not just about ending pregnancies. Peacock recalled a patient who started hemorrhaging badly shortly after a healthy delivery. Peacock and her team at UCSF performed a dilation and curettage — a procedure commonly used to terminate pregnancy.

“If we did not have that skill set, and the patient continued to bleed, it could have been life-taking,” said Peacock, chief OB-GYN resident at UCSF.

It’s not yet clear how many spots will be available in California to train out-of-state medical residents as demand ratchets up. “Many sites were already at their training maximums and are unable to expand opportunities to others,” said Michael Belmonte, a fellow with the American College of Obstetricians and Gynecologists.

Between , when Roe was overturned, and the end of June 2023, 125 out-of-state doctors did residencies in programs that use the model, according to Kristin Simonson, director of programs and operations. Ryan helps OB-GYN residency programs integrate comprehensive abortion care training.

Even when opportunities to learn abortion care are available, those seeking training are proceeding with caution. “Residents arranging to travel for abortion training, like patients who travel for abortion care, are making arrangements quietly so they do not draw unwanted attention or repercussions,” said Janet Jacobson, medical director and senior vice president of clinical services at Planned Parenthood of Orange and San Bernardino Counties, which just trained its first resident from a state with an abortion ban.

Statistics on harassment and attacks against abortion providers or disruption of their work back up such concerns, even in states where abortions are allowed. From 2021 to 2022, for example, there were upticks in stalking of personnel, bomb threats, assault and battery, and obstruction, according to the from the National Abortion Federation.

Jessica Mecklosky, a pediatric resident at UCSF, said she hopes to focus on adolescent medicine, including reproductive health, where she can offer young patients choices about their futures. Her medical school experience in Louisiana, she said, is a prime example of why abortion training in California and other states is so crucial.

She initially wanted to specialize in obstetrics and gynecology but switched to pediatrics, which also would involve reproductive health care. Although she knew Louisiana had abortion restrictions, she didn’t realize how much those restrictions would interfere with her ability to learn: There were just three abortion clinics in the entire state, and as she soon found out, none were available for her training.

“I was actually not going to be able to see any elective abortion procedures throughout medical school, because we don’t rotate through any abortion clinics,” she said. There was an opportunity for a day’s training in her third year, “but, unfortunately, Roe fell before I was able to do that.”

Through , a group that provides stipends of up to $1,200, Mecklosky got an abortion care rotation at Montefiore Medical Center in New York during her summer break.

Mecklosky is torn about where she’ll land after her residency. She may return to Louisiana and advocate for legislative changes in reproductive health while attending to patients and making forays to other states to provide abortions.

She recounts an experience in New Orleans when the Dobbs v. Jackson Women’s Health Organization decision, which undid Roe, was imminent that is etched into her memory. “I had actually seen a few patients who were minors, were pregnant, and wanted to terminate their pregnancies,” she said, noting that they could not afford to travel for an abortion. “And I just remember having this sense of dread, just knowing that if we couldn’t get them into an appointment in the next 24 or 48 hours, it was possible that they would not be able to do it.”

Peacock, for her part, is adamant about returning to Georgia, where abortions are banned after six weeks. “I’m still going to provide abortions, whether that’s in Georgia or I need to fly to a different state and work in abortion clinics for a week out of the month,” she said. “It would definitely be a big part of my work.”

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“I want to scream!” one called out. “I feel exhausted,” said another.

Espedal, who has been training caregivers for 18 years, guided the class through a self-soothing exercise: “Breathe in for four counts, hold the breath for four, exhale for four.” She taught them to carve out time for themselves, such as setting the goal of reading a book from beginning to end, and reminded everyone to eat, sleep, and exercise. “Do not be afraid to ask for help,” Espedal said. She added that one of the best ways they can care for their clients — often a loved one — was to care for themselves.

The class is a little touchy-feely. But it’s one of many offerings from the California Department of Social Services that the agency says is necessary for attracting and retaining caregivers in a that helps 650,000 low-income people who are older or disabled age in place, usually at home. As part of the $295 million initiative, officials said, thousands of classes, both online and in-person, will begin rolling out in January, focused on dozens of topics, including dementia care, first-aid training, medication management, fall prevention, and self-care. Caregivers will be paid for the time they spend developing skills.

Whether it will help the program’s labor shortage remains to be seen. According to a of the In-Home Supportive Services program, 32 out of 51 counties that responded to a survey reported a shortage of caregivers. Separately, auditors found that clients waited an average of to be approved for the program, although the department said most application delays were due to missing information from the applicants.

The in-home assistance program, which has been around for , is plagued by high turnover. About 1 in 3 caregivers leave the program each year, according to University of California-Davis researcher Heather Young, who worked on a 2019 on California’s health care workforce needs.

It doesn’t help that the pay is low. , the average hourly rate for caregivers in the in-home assistance program is $15.83. Rates vary because the program is administered locally, with each county setting its own.

“Training is very helpful,” said Doug Moore, executive director of the United Domestic Workers of America AFSCME Local 3930, which represents roughly 150,000 caregivers in California. “But when the wages are low — and you can make more at Target or McDonald’s and get a signing bonus — then you’re going to go and do that work versus harder work, which is taking care of someone with a disability or a person that’s aging.”

The training initiative came out of Gov. Gavin Newsom’s Master Plan for Aging to . Theresa Mier, a spokesperson for the Department of Social Services, said the state hopes financial incentives will help attract new workers and keep them caring for people with specialized needs longer. In addition to their hourly pay for taking classes, in-home caregivers will receive incentive payments that start at $500 for 15 hours of training. They can if they go on to work at least 40 hours a month with a qualified client for at least six months. Previously, counties offered some training but did not pay workers for their time.

The state issued grants, including to Homebridge, a San Francisco-based caregiving organization, to coordinate training. Classes will be offered in Spanish, Cantonese, Mandarin, and Armenian, in addition to English, to reach more workers. And state officials are planning a social media campaign to recruit new caregivers.

But the incentives are committed only through the end of 2023.

Greg Thompson, executive director of the , the public authority that manages Los Angeles County’s in-home program, would like to see paid training become permanent. “There needs to be, in my opinion, some kind of accountability, structure, supervision, and ongoing training,” he said.

Many caregivers who attended early courses care for family members with a mix of physical and behavioral needs. In fact, 3 out of 4 caregivers in the in-home assistance program are relatives of clients. But the state needs to prepare for a workforce shift, one that requires people to look outside their families. The number of California seniors is expected to be nearly 8.5 million by 2030, an from 2019. Many of them will be single.

The state will need more caregivers like Luz Maria Muñoz, who has worked in the in-home assistance program for six years. The Bakersfield resident has navigated challenging situations on the job. One older client was on 30 medications. Another had bedsores, which can be life-threatening if not properly treated. Muñoz peppered the client’s nurse with questions about dressing the wounds and felt responsible for the client’s well-being.

“Those wounds needed to be cleaned daily,” she said.

Muñoz said she’s interested in the training. The department said it sent notices about classes to all participating caregivers and will follow up with updates. Counties also helped spread the word online, in newsletters, and via posted flyers.

Early sessions have filled up as soon as they’re set up. Leslie Kerns, the in-home assistance registry manager for , the public authority for the program in Nevada, Plumas, and Sierra counties, said some classes were full after three hours. State officials said next year should open soon.

Angelina Williamson cares for her mother, who is disabled, in San Diego and took a course on mobility and transferring patients. She said she learned how to use her body to break a fall and that if her mother falls, it’s better to bring her a chair than pick her up because her mother has enough upper body strength to pull herself up, with Williamson’s help.

Recent surveys suggest that caregivers are likely to be interested in self-care. In a in California, 35% of caregivers reported that their health had worsened while providing care, and 20% had experienced symptoms of depression. Some caregivers also reported being lonely, which could include lacking companionship, feeling left out, or feeling isolated from others. And a by the National Alliance for Caregiving and AARP found that 26% of caregivers had difficulty managing their stress.

Robbie Glenn, a single father in Anaheim, attended Espedal’s self-care class and learned to take time for himself. By day, Glenn cares for his 11-year-old son, Edin, who has birth defects from alcohol exposure and has nonverbal autism. Edin needs help going to the toilet and bathing. He has epilepsy and sometimes walks in his sleep. By night, Glenn freelances, doing post-production work, such as film editing and .

Glenn now uses a timer to remind himself to take a break. “And,” he said, “I’ve been doing those breathing exercises a lot.”

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A bill before Gov. Gavin Newsom would bar anyone under 18 in California from buying over-the-counter weight loss supplements — whether online or in shops — without a prescription. A similar bill passed by New York lawmakers is on Gov. Kathy Hochul’s desk. Neither Democrat has indicated how he or she will act.

If both bills are signed into law, proponents hope the momentum will build to restrict diet pill sales to children in more states. Massachusetts, New Jersey, and Missouri have introduced and backers plan to continue their push next year.

Nearly people in the United States will have an eating disorder in their lifetime; 95% of them are between ages 12 and 25, according to Johns Hopkins All Children’s Hospital. The hospital adds that eating disorders pose the highest risk of mortality of any mental health disorder. And it has become easier than ever for minors to get pills that are sold online or on drugstore shelves. All dietary supplements, which include those for weight loss, accounted for nearly 35% of the over-the-counter health products industry in 2021, according to Vision Research Reports, a market research firm.

Dietary supplements, which encompass a broad range of vitamins, herbs, and minerals, are and don’t undergo scientific and safety testing as prescription drugs and over-the-counter medicines do.

Public health advocates want to keep weight loss products — with ads that may promise to and pill names like Slim Sense — away from young people, particularly girls, since some research has linked some products to eating disorders. A , which followed more than 10,000 women ages 14-36 over 15 years, found that “those who used diet pills had more than 5 times higher adjusted odds of receiving an eating disorder diagnosis from a health care provider within 1 to 3 years than those who did not.”

Many pills have been found tainted with banned and dangerous ingredients that may cause cancer, heart attacks, strokes, and other ailments. For example, the FDA Slim Sense by Dr. Reade because it contains lorcaserin, which has been found to cause psychiatric disturbances and impairments in attention or memory. The FDA ordered it discontinued and the company couldn’t be reached for comment.

“Unscrupulous manufacturers are willing to take risks with consumers’ health — and they are lacing their products with illegal pharmaceuticals, banned pharmaceuticals, steroids, excessive stimulants, even experimental stimulants,” said Bryn Austin, founding director of the Strategic Training Initiative for the Prevention of Eating Disorders, or STRIPED, which supports the restrictions. “Consumers have no idea that this is what’s in these types of products.”

STRIPED is a public health initiative based at the Harvard T.H. Chan School of Public Health and Boston Children’s Hospital.

An industry trade group, the Natural Products Association, disputes that diet pills cause eating disorders, citing the lack of consumer complaints to the FDA of adverse events from their members’ products. “According to FDA data, there is no association between the two,” said Kyle Turk, the association’s director of government affairs.

The association contends that its members adhere to safe manufacturing processes, random product testing, and appropriate marketing guidelines. Representatives also worry that if minors can’t buy supplements over the counter, on the black market and undermine the integrity of the industry. Under the bills, minors purchasing weight loss products must show identification along with a prescription.

Not all business groups oppose the ban. The American Herbal Products Association, a trade group representing dietary supplement manufacturers and retailers, dropped its opposition to California’s bill once it was amended to remove ingredient categories that are found in non-diet supplements and vitamins, according to Robert Marriott, director of regulatory affairs.

Children’s advocates have found worrisome trends among young people who envision their ideal body type based on what they see on social media. According to a study , a nonprofit that seeks to stop harmful marketing practices targeting children, kids as young as 9 were found to be following three or more eating disorder accounts on Instagram, while the median age was 19. The authors called it a “.”

Meta, which owns Instagram and Facebook, said the report lacks nuance, such as recognizing the human need to share life’s difficult moments. The company argues that blanket censorship isn’t the answer. “Experts and safety organizations have told us it’s important to strike a balance and allow people to share their personal stories while removing any content that encourages or promotes eating disorders,” said Liza Crenshaw, a Meta spokesperson, in an email.

Dr. Jason Nagata, a pediatrician who cares for children and young adults with life-threatening eating disorders, believes that easy access to diet pills contributes to his patients’ conditions at UCSF Benioff Children’s Hospital in San Francisco. That was the case for one of his patients, an emaciated 11-year-old girl.

“She had basically entered a starvation state because she was not getting enough nutrition,” said Nagata, who provided supporting testimony for the California bill. “She was taking these pills and using other kinds of extreme behaviors to lose weight.”

Nagata said the number of patients he sees with eating disorders has tripled since the pandemic began. They are desperate to get diet pills, some with modest results. “We’ve had patients who have been so dependent on these products that they will be hospitalized and they’re still ordering these products on Amazon,” he said.

Public health advocates turned to state legislatures in response to the federal government’s limited authority to regulate diet pills. Under a 1994 federal law known as the , the FDA “cannot step in until after there is a clear issue of harm to consumers,” said Austin.

No match for the supplement industry’s on Capitol Hill, public health advocates shifted to a state-by-state approach.

There is, however, a push for the FDA to improve oversight of what goes into diet pills. U.S. Sen. Dick Durbin of Illinois in April introduced that would require dietary supplement manufacturers to register their products — along with the ingredients — with the regulator.

Proponents say the change is needed because manufacturers have been known to include dangerous ingredients. C. Michael White of the University of Connecticut’s School of Pharmacy found in a review of a health fraud database.

A few ingredients have been banned, including sibutramine, a stimulant. “It was a very commonly used weight loss supplement that ended up being removed from the U.S. market because of its elevated risk of causing things like heart attacks, strokes, and arrhythmias,” White said.

Another ingredient was phenolphthalein, which was used in laxatives until it was identified as a suspected carcinogen and banned in 1999. “To think,” he said, “that that product would still be on the U.S. market is just unconscionable.”

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Allen’s crying may be distressing, but his wide-open mouth allows Calvo to begin the exam. She counts his baby teeth and checks for dental decay.

“Nothing I am going to do will hurt him,” Calvo tells Allen’s mother, Maritza Barron, who is holding her son’s hands.

To some, the 20-month-old toddler may seem far too young for a dental exam. In fact, he’s on the late side, according to .

To stave off a lifetime of dental problems and make sure parents learn how to prevent children’s tooth decay, babies should have their first exam when they get their first tooth, or no later than their 1st birthday, according to from the American Academy of Pediatric Dentistry.

However, many dentists are uncomfortable treating babies, and that has created a significant gap in dental care for infants and toddlers of all backgrounds, experts say. The shortfall is hard to quantify because professional organizations, such as the American Dental Association, do not survey their members on whether they care for infants.

“People think that children are afraid of dentists, but really it’s that dentists are afraid of children,” said Pamela Alston, who is a dentist and dental director of the Oakland-based Eastmont Wellness Center, a publicly funded clinic that is part of the county-run Alameda Health System.

Hoping to narrow the gap in care, the public health agencies of San Francisco and Alameda counties are launching pilot programs to train dentists to treat babies. About 70 dentists will learn over the next three years how to coax infants into cooperating and help parents guard against tooth decay. The first training session in Alameda County is scheduled for early November; San Francisco will begin its training in January. The American Dental Association was not aware of any similar programs in other states.

The guidelines calling for earlier dental visits stemmed from a growing awareness that cavity-causing bacteria , through shared utensils, for example. Giving babies bottles of fruit juice or sugar water also can cause cavities. Decay in baby teeth has been linked to adult tooth decay.

“By the time children are age 3, they are often so far down the road that prevention is no longer an option,” said Ray Stewart, a pediatric dental professor at UCSF, who has treated infants for more than 15 years and is among the professionals enlisted by Alameda and San Francisco to train the dentists.

Dentists don’t regard exams of very young children as a means of boosting their income, said Alicia Malaby, spokeswoman for the California Dental Association. “Denti-Cal reimbursements are below actual costs for many procedures,” she said. Rather, they want to help “improve community health outcomes.”

Low-income children, who are and have to care than their affluent peers, present the greatest need for early oral exams, dental professionals say.

A portion of the revenue from California’s new tobacco tax will be earmarked to help very young children from low-income families get the dental care they need. The money will be used to give dentists a 40 percent increase on top of the standard reimbursement for services to Denti-Cal patients, including oral exams of children age 3 and under. Denti-Cal provides dental care to beneficiaries of Medi-Cal, California’s version of Medicaid.

Alameda County will offer dentists an extra $20, on top of that statewide increase for appointments with Denti-Cal-covered children that include a thorough exam of the baby’s mouth, a fluoride varnish if needed, a talk with parents about prevention and a demonstration of how to brush their baby’s teeth.

The Alameda and San Francisco training programs, funded by grants from Medi-Cal, could be replicated throughout California if they are successful, according to the Department of Health Care Services.

Maritza Barron came to UCSF after her own dentist — despite the best of intentions — was unable to examine her baby’s mouth. “He tried to say ‘open up’ to him but he wouldn’t do it,” Barron said of the failed attempt, which left her son in tears.

Alston, the Oakland dentist, once faced similar challenges treating very young children, but she has since undergone a transformation. She blames dentists’ wariness of young patients on a lack of experience. When she graduated from dental school in 1982, she said, she had no training that prepared her to work with children younger than 6.

“I didn’t feel like I could manage their behavior,” Alston said.

Over time, however, it became increasingly clear to her that she wasn’t seeing children early enough.

Almost all of the kids who came to her for their first dental visit at age 6 had mouths riddled with tooth decay, Alston said. She had to refer them to specialists for treatment that required sedation. She kept lowering the minimum age for a first visit in her practice, then left it at age 3 for a long time.

But even 3-year-olds were coming in with cavities. Ultimately, she learned how to treat infants and toddlers through a program run by Alameda County’s public health department — not unlike the training to be offered by the new pilot programs.

Today, Alston is passionate about treating very young children and has lined up pediatricians to refer infants to her. And she has revised her guidance on when kids should get their first oral exam, advising parents to bring their children in when their first tooth starts to erupt.

People think that children are afraid of dentists, but really it’s that dentists are afraid of children.

Pamela Alston, Eastmont Wellness Center

She also trains dental students to examine infants. An important trick she teaches them is how to avoid being bitten: “Put your finger behind the last tooth!”

Communicating directly with children during dental exams can help reduce their stress, saod both Alston and Stewart, the UCSF dental professor.

At a recent visit to UCSF’s Pediatric Dentistry Faculty Clinic, 18-month-old Sebastian King scrutinized the dental mirror Stewart handed to him.

“That’s what I’m going to put in your mouth to look at your teeth!” Stewart told him exuberantly.

He asked the young boy to show him where his mouth was. Sebastian smiled with delight as Stewart handed him a blue exam glove he’d blown up into a balloon, and the young boy remained calm throughout the exam.

Helping parents understand their role is also critical, dentists say.

In addition to advising parents not to share eating utensils with their children, Stewart urges them not to let their kids fall asleep with a bottle of milk and to limit their consumption of fruit juice. He also says they should wipe their infants’ gums and teeth with a cloth after feeding them to remove residue that can cause cavities.

That’s the message Calvo, the dental resident, gave to Barron, whose baby sat happily on his mother’s lap after his exam. The boy had cavities because he had been falling asleep with his bottle.

Barron said she recognized that weaning Allen from the bottle at night would be a challenge.

But “it’s really logical,” she told Calvo, adding that she was determined to give it a try.

This story was produced by , which publishes , an editorially independent service of the .

KHN’s coverage of children’s health care issues is supported in part by a grant from .

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Strolling through the clinic, one of the first of its kind in the nation, founder Dr. David Smith points to a large collage that decorates a wall of an exam room affectionately referred to as the Psychedelic Wall of Fame. The 1967 relic shows a kaleidoscope of images of Jefferson Airplane and other legendary counterculture bands, floating in a dreamscape of creatures, nude goddesses, peace symbols and large loopy letters.

“That was made by a woman who had just taken LSD. She stayed here for a very long time and put all that up. It lasted as long as her LSD trip,” Smith said moving on to what was once called the “bad trip” room, where clinic staff would talk down clients during acid trips gone awry.

Fundamentally, Smith and others say, the organization has remained true to its counterculture roots, still offering free care in a deliberately nonjudgmental atmosphere.

But it is also drastically different: It is now the Haight Ashbury Free Clinics — plural — and part of a multi-million-dollar conglomerate with the decidedly un-hippie name ofÌý.

All told, HealthRIGHT 360 serves approximately 40,000 patients each year in a wide range of programs, including “reentry” services to formerly incarcerated adults and teens, residential and outpatient drug treatment, mental health care and medical and dental care. In 2014, it purchased a 50,000 square foot building at 1563 Mission Street in San Francisco as additional space to offer all of these services under one roof. The organization also serves patients inÌýo andÌýÌýcounties.

It’s been a long journey from Smith’s early days running a standalone clinic.

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When the clinic first opened, it operated 24 hours a day with an army of volunteer physicians from the University of California-San Francisco and Stanford. The one paid staffer was a nurse. The first year’s budget was her salary: $25,000.

It had a “guerilla” pharmacy, Smith said. Pharmaceutical representatives would load up their trunks with medication samples and drop them off at the clinic, where a team of UCSF volunteer pharmacists bottled up the medication and shelved it, according to Smith, who noted wryly that the illegal activity long ago reached its “statute of limitations.”

“Our first exam table was my kitchen table,” he recalls. Decisions were made by consensus, and even the janitor weighed in, Smith said.

Benefit rock concerts organized by the iconic music promoter Bill Graham, featuring performances by George Harrison and Janis Joplin, helped the clinic stay afloat financially.

Smith remembers when Joplin overdosed on heroin, and the clinic rushed over an “overdose team” armed with the anti-opioid medication naloxone: “We zipped out there and reversed her overdose,” recalls Smith.

As Smith tells it, many Vietnam veterans returned from the war in the early 1970s addicted to heroin. They felt ostracized by what was then called the Veterans Administration and headed to Haight Ashbury and its clinic, which by then offered comprehensive medical cares and a drug detox program.

The influx of veterans led to federal grants from Special Action Office on Drug Abuse Prevention. “That began the government funding era in the 1970s and ensured our survival,” said Smith.

In the 1980s, a young woman named Vitka Eisen learned firsthand the value of the personal attention the clinic offered. She came to the Haight Ashbury clinic struggling with heroin addiction. “I went there for detox at least nine times,” she said. “I never felt shamed or judged. They always acted like they were glad to see me.”

Her trust in the staff led her to kick her heroin habit and return to school, where she eventually earned a doctorate in education from Harvard.

Eisen took the helm as CEO of HealthRIGHT360 in 2010.

The clinics’ business model began to change dramatically in 2007, when it added another site at 1735 Mission Street, San Francisco.

But by 2011, like many recession-era nonprofits, the clinics were deeply in debt, Smith said. So they merged with the renowned San Francisco-based addiction and mental health treatment program, Walden House, which wanted to offer comprehensive medical care to its patients. The two nonprofits merged, and adopted the name HealthRIGHT360.

By joining forces in 2011, Walden House and the Haight Ashbury Free Clinics were able to weather the extraordinary financial expense of shifting their organizations to electronic health records, a requirement of the Affordable Care Act, said Eisen.

With the system in place, she said, it’s easy enough to train and add on new providers as HealthRight360 has expanded. The merger also allowed the Haight Ashbury Free Clinics to erase its debt in a year.

Between then and its latest merger in July with Prototypes, a Southern California women’s drug treatment center, HealthRIGHT360 has acquired five other community clinics in Northern California and offers treatment at 40 sites up and down the state, according to its former Vice President of Development Michelle Hudson.

Ben Avey, assistant director for external affairs at the California Primary Care Association, said such mergers aren’t new, but they have accelerated under the now-imperiled ACA.

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At the individual clinics that comprise health systems like HealthRIGHT360, “they speak your language, know your culture, understand the situation you’re coming from,” Avey added.

As CEO, Eisen led the consolidation that streamlined HealthRIGHT 360. “We have one board, one human resources department, one finance department, one payroll department and one executive.” The annual revenue, said Eisen, is $110 million. Medi-Cal, the city, county, state and federal governments reimburse HealthRIGHT 360 for providing patient services, as do commercial health insurers.

But ties to the early days remain. The early treatment of concertgoers evolved into San Francisco-based Rock Medicine, which is now part of HealthRight360 and sets up on site at rock concerts, circuses and fairs in the San Francisco Bay Area and Los Angeles garnering $1,038,000 annually from the venues.

And the non-judgmental reception by the Haight Ashbury Free Clinics’ staff continues to this day, according to 61-year-old David Smith, (no relation to the clinic founder) who has been coming to the clinic since the 1980s and has always felt welcomed and accepted.

This was true even when Smith was homeless in the early 2000s.

“It didn’t matter if I was dirty,” he says. “I didn’t have to feel like I couldn’t come in here because I wasn’t in the proper state of cleanliness, which was unfortunately the case for a quite bit of the time.”

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The latest move is a law that enables trained physician assistants, also known as physician associates, to perform first-trimester abortions without a supervising physician present. The measure, which passed last year and took effect Jan. 1, also lets PAs who have been disciplined or convicted solely for performing an abortion in a state where the practice is restricted apply for a license in California.

Physician assistants are now on par with nurse practitioners and certified nurse midwives trained in abortion care, who in 2022 won the ability to perform abortions without a doctor present.

The need for more abortion care practitioners is being driven by efforts in many states to gut abortion rights following the Supreme Court’s 2022 decision ending constitutional protection for the procedure. have implemented abortion restrictions that range from cutting federal funding for abortion coverage to outright bans, according to the Guttmacher Institute, a research organization concerned with reproductive health.

With the new law, “there will be fewer barriers, and shorter wait times for this essential service,” said Jeremy Meis, president-elect of the California Academy of Physician Associates. While it is unclear how many of California’s 16,000 PAs will be trained in performing abortions, that PAs are more likely than physicians to practice in rural areas where access to abortion is limited. More than in California lack clinics that provide abortion.

Comparing data from the first six months of 2020 with the same period in 2023, the number of abortions jumped from a 20% increase as the state became a refuge for women seeking abortions. California has passed a suite of to build in protections and increase access, and a dozen other states, including Oregon, Minnesota, and New York, have mounted similar efforts. Seventeen states, including California, now allow PAs to perform first-trimester abortions, according to the American Academy of Physician Associates.

There was little opposition to the new California law, with two physicians’ groups supporting it. But the American Medical Association, the country’s most powerful doctors’ lobby, has fought vigorously against what it calls “” — that is, changes that allow clinicians like PAs to do medical procedures independent of physicians.

“Our policy stance is the same on scope of practice expansion regardless of procedure,” noted Kelly Jakubek, the AMA’s media relations manager. The AMA’s website points to legislative victories in 2023, including striking down “legislation allowing physician assistants to practice independently without physician oversight,” in states including Arizona and New York. The AMA did not take a formal position on the California legislation. Its local chapter, the California Medical Association, took a neutral position on the legislation.

In preparation for the new law, one physician assistant at Planned Parenthood Pasadena & San Gabriel Valley began learning how to perform aspiration abortions — a procedure also known as dilation and curettage that uses gentle suction to end a pregnancy — at the end of last year. The PA, who requested anonymity due to concerns about safety, said that with abortion restrictions in place around the country, “I just think it’s really important to be able to provide a comfortable, safe, and very effective way to terminate a pregnancy for patients.”

She is now one of six PAs and midwives at her clinic who can offer aspiration abortions. To reach competency, she participated in 50 procedures and learned how to administer medication that eases pain and anxiety. Such , as it is known, is frequently used for first-trimester abortions. Now she, like any other advanced practice clinician who has obtained skills in performing abortions, can train her peers — another feature of the new law.

The length of time for training and the number of procedures to reach competency varies based on a practitioner’s previous experience.

“It’s encouraging this cross-profession training and collaborations, which is really important when we’re looking at increasing access to essential services,” said Jessica Dieseldorff, senior program manager of abortion services at Planned Parenthood Mar Monte in Santa Cruz.

In December, California committed $18 million to help accelerate training in abortion and reproductive care for practitioners, including PAs, through the Reproductive Health Care Access Initiative.

Dieseldorff, a nurse practitioner who trains other advanced-practice clinicians in abortion care, said that rural communities, in particular, will reap the benefits since many rely solely on physician assistants and other allied clinicians.

Reflecting on her career, she said much has changed since she became a nurse 25 years ago. At that time, she worked only as support staff to doctors providing abortions.

“When I began, did not exist in this country,” she said, referring to the practice of using two drugs often prescribed to induce abortions. “It’s been gratifying to be able to progress and become a provider myself, provide non-stigmatizing and compassionate and safe care to patients; and now, at this stage in my career to be training others to do the same.”

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Her commitment to becoming a maternal health care provider was sparked early on when she witnessed the discrimination and judgment leveled against her older sister, who became a mother as a teen. When the Supreme Court overturned Roe v. Wade in 2022, Peacock was already in her residency program in California, and her thoughts turned back to women like her sister.

“I knew that the people — my people, my community back home — was going to be affected in a dramatic way, because they’re in the South and because they’re Black,” she said.

But even though Peacock attended the Medical College of Georgia, she’s doing her obstetrics and gynecology residency at the University of California-San Francisco, where she has gotten comprehensive training in abortion care.

“I knew as a trainee that’s what I needed,” said Peacock, who plans to return to her home state after her residency.

Ever since the Supreme Court decision, California has worked to become a sanctuary for people from states where abortion is restricted. In doing so, it joins 14 other states, including Colorado, New Mexico, and Massachusetts. Now, it’s addressing the fraught issue of abortion training for medical residents, which most doctors believe is crucial to comprehensive OB-GYN training.

A law makes it easier for out-of-state trainees to get up to 90 days of in-person training under the supervision of a California-licensed doctor. The law eliminated the requirement for a training license and also permitted training at programs such as Planned Parenthood that are affiliated with accredited medical schools.

“By allowing physician residents to come to California, where there are more opportunities for abortion training, and by allowing them to be reimbursed for this work, we’re sending a message that abortion care is health care and an essential part of physician training,” said Lisa Folberg, CEO of the California Academy of Family Physicians, which supported the bill.

The question of how to provide complete OB-GYN training promises to become more urgent as the effects of abortion bans on medical education become clear: restrict or ban abortion to the point of effectively stripping 20% of OB-GYN medical residents of the opportunity to get abortion training, according to the in Abortion and Family Planning. That’s 1,354 residents this year out of 5,962 OB-GYN residents nationwide.

The restrictions in some cases aim to reach beyond state borders, spooking medical students and residents who fear hostility from anti-abortion groups and right-wing legislators.

One OB-GYN resident in a state with abortion restrictions, who asked to remain anonymous for fear of reprisals, said she’s keen on getting comprehensive abortion care training in California — but can’t.

“My program will not allow us to perform abortions in other states,” she said.

She said administrators worry that doing so would subject residents to litigation because the program is state-funded.

“That is how my program is interpreting the law,” she said. “They’re being very conservative in order to protect us.”

Pamela Merritt, executive director of , pointed to a Kansas law that requires repayment of state medical school scholarships — with 15% interest — if residents perform abortions or work in clinics that perform them, except in cases of rape, incest, or a medical emergency.

Doctors point out that abortion training is not just about ending pregnancies. Peacock recalled a patient who started hemorrhaging badly shortly after a healthy delivery. Peacock and her team at UCSF performed a dilation and curettage — a procedure commonly used to terminate pregnancy.

“If we did not have that skill set, and the patient continued to bleed, it could have been life-taking,” said Peacock, chief OB-GYN resident at UCSF.

It’s not yet clear how many spots will be available in California to train out-of-state medical residents as demand ratchets up. “Many sites were already at their training maximums and are unable to expand opportunities to others,” said Michael Belmonte, a fellow with the American College of Obstetricians and Gynecologists.

Between , when Roe was overturned, and the end of June 2023, 125 out-of-state doctors did residencies in programs that use the model, according to Kristin Simonson, director of programs and operations. Ryan helps OB-GYN residency programs integrate comprehensive abortion care training.

Even when opportunities to learn abortion care are available, those seeking training are proceeding with caution. “Residents arranging to travel for abortion training, like patients who travel for abortion care, are making arrangements quietly so they do not draw unwanted attention or repercussions,” said Janet Jacobson, medical director and senior vice president of clinical services at Planned Parenthood of Orange and San Bernardino Counties, which just trained its first resident from a state with an abortion ban.

Statistics on harassment and attacks against abortion providers or disruption of their work back up such concerns, even in states where abortions are allowed. From 2021 to 2022, for example, there were upticks in stalking of personnel, bomb threats, assault and battery, and obstruction, according to the from the National Abortion Federation.

Jessica Mecklosky, a pediatric resident at UCSF, said she hopes to focus on adolescent medicine, including reproductive health, where she can offer young patients choices about their futures. Her medical school experience in Louisiana, she said, is a prime example of why abortion training in California and other states is so crucial.

She initially wanted to specialize in obstetrics and gynecology but switched to pediatrics, which also would involve reproductive health care. Although she knew Louisiana had abortion restrictions, she didn’t realize how much those restrictions would interfere with her ability to learn: There were just three abortion clinics in the entire state, and as she soon found out, none were available for her training.

“I was actually not going to be able to see any elective abortion procedures throughout medical school, because we don’t rotate through any abortion clinics,” she said. There was an opportunity for a day’s training in her third year, “but, unfortunately, Roe fell before I was able to do that.”

Through , a group that provides stipends of up to $1,200, Mecklosky got an abortion care rotation at Montefiore Medical Center in New York during her summer break.

Mecklosky is torn about where she’ll land after her residency. She may return to Louisiana and advocate for legislative changes in reproductive health while attending to patients and making forays to other states to provide abortions.

She recounts an experience in New Orleans when the Dobbs v. Jackson Women’s Health Organization decision, which undid Roe, was imminent that is etched into her memory. “I had actually seen a few patients who were minors, were pregnant, and wanted to terminate their pregnancies,” she said, noting that they could not afford to travel for an abortion. “And I just remember having this sense of dread, just knowing that if we couldn’t get them into an appointment in the next 24 or 48 hours, it was possible that they would not be able to do it.”

Peacock, for her part, is adamant about returning to Georgia, where abortions are banned after six weeks. “I’m still going to provide abortions, whether that’s in Georgia or I need to fly to a different state and work in abortion clinics for a week out of the month,” she said. “It would definitely be a big part of my work.”

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“I want to scream!” one called out. “I feel exhausted,” said another.

Espedal, who has been training caregivers for 18 years, guided the class through a self-soothing exercise: “Breathe in for four counts, hold the breath for four, exhale for four.” She taught them to carve out time for themselves, such as setting the goal of reading a book from beginning to end, and reminded everyone to eat, sleep, and exercise. “Do not be afraid to ask for help,” Espedal said. She added that one of the best ways they can care for their clients — often a loved one — was to care for themselves.

The class is a little touchy-feely. But it’s one of many offerings from the California Department of Social Services that the agency says is necessary for attracting and retaining caregivers in a that helps 650,000 low-income people who are older or disabled age in place, usually at home. As part of the $295 million initiative, officials said, thousands of classes, both online and in-person, will begin rolling out in January, focused on dozens of topics, including dementia care, first-aid training, medication management, fall prevention, and self-care. Caregivers will be paid for the time they spend developing skills.

Whether it will help the program’s labor shortage remains to be seen. According to a of the In-Home Supportive Services program, 32 out of 51 counties that responded to a survey reported a shortage of caregivers. Separately, auditors found that clients waited an average of to be approved for the program, although the department said most application delays were due to missing information from the applicants.

The in-home assistance program, which has been around for , is plagued by high turnover. About 1 in 3 caregivers leave the program each year, according to University of California-Davis researcher Heather Young, who worked on a 2019 on California’s health care workforce needs.

It doesn’t help that the pay is low. , the average hourly rate for caregivers in the in-home assistance program is $15.83. Rates vary because the program is administered locally, with each county setting its own.

“Training is very helpful,” said Doug Moore, executive director of the United Domestic Workers of America AFSCME Local 3930, which represents roughly 150,000 caregivers in California. “But when the wages are low — and you can make more at Target or McDonald’s and get a signing bonus — then you’re going to go and do that work versus harder work, which is taking care of someone with a disability or a person that’s aging.”

The training initiative came out of Gov. Gavin Newsom’s Master Plan for Aging to . Theresa Mier, a spokesperson for the Department of Social Services, said the state hopes financial incentives will help attract new workers and keep them caring for people with specialized needs longer. In addition to their hourly pay for taking classes, in-home caregivers will receive incentive payments that start at $500 for 15 hours of training. They can if they go on to work at least 40 hours a month with a qualified client for at least six months. Previously, counties offered some training but did not pay workers for their time.

The state issued grants, including to Homebridge, a San Francisco-based caregiving organization, to coordinate training. Classes will be offered in Spanish, Cantonese, Mandarin, and Armenian, in addition to English, to reach more workers. And state officials are planning a social media campaign to recruit new caregivers.

But the incentives are committed only through the end of 2023.

Greg Thompson, executive director of the , the public authority that manages Los Angeles County’s in-home program, would like to see paid training become permanent. “There needs to be, in my opinion, some kind of accountability, structure, supervision, and ongoing training,” he said.

Many caregivers who attended early courses care for family members with a mix of physical and behavioral needs. In fact, 3 out of 4 caregivers in the in-home assistance program are relatives of clients. But the state needs to prepare for a workforce shift, one that requires people to look outside their families. The number of California seniors is expected to be nearly 8.5 million by 2030, an from 2019. Many of them will be single.

The state will need more caregivers like Luz Maria Muñoz, who has worked in the in-home assistance program for six years. The Bakersfield resident has navigated challenging situations on the job. One older client was on 30 medications. Another had bedsores, which can be life-threatening if not properly treated. Muñoz peppered the client’s nurse with questions about dressing the wounds and felt responsible for the client’s well-being.

“Those wounds needed to be cleaned daily,” she said.

Muñoz said she’s interested in the training. The department said it sent notices about classes to all participating caregivers and will follow up with updates. Counties also helped spread the word online, in newsletters, and via posted flyers.

Early sessions have filled up as soon as they’re set up. Leslie Kerns, the in-home assistance registry manager for , the public authority for the program in Nevada, Plumas, and Sierra counties, said some classes were full after three hours. State officials said next year should open soon.

Angelina Williamson cares for her mother, who is disabled, in San Diego and took a course on mobility and transferring patients. She said she learned how to use her body to break a fall and that if her mother falls, it’s better to bring her a chair than pick her up because her mother has enough upper body strength to pull herself up, with Williamson’s help.

Recent surveys suggest that caregivers are likely to be interested in self-care. In a in California, 35% of caregivers reported that their health had worsened while providing care, and 20% had experienced symptoms of depression. Some caregivers also reported being lonely, which could include lacking companionship, feeling left out, or feeling isolated from others. And a by the National Alliance for Caregiving and AARP found that 26% of caregivers had difficulty managing their stress.

Robbie Glenn, a single father in Anaheim, attended Espedal’s self-care class and learned to take time for himself. By day, Glenn cares for his 11-year-old son, Edin, who has birth defects from alcohol exposure and has nonverbal autism. Edin needs help going to the toilet and bathing. He has epilepsy and sometimes walks in his sleep. By night, Glenn freelances, doing post-production work, such as film editing and .

Glenn now uses a timer to remind himself to take a break. “And,” he said, “I’ve been doing those breathing exercises a lot.”

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A bill before Gov. Gavin Newsom would bar anyone under 18 in California from buying over-the-counter weight loss supplements — whether online or in shops — without a prescription. A similar bill passed by New York lawmakers is on Gov. Kathy Hochul’s desk. Neither Democrat has indicated how he or she will act.

If both bills are signed into law, proponents hope the momentum will build to restrict diet pill sales to children in more states. Massachusetts, New Jersey, and Missouri have introduced and backers plan to continue their push next year.

Nearly people in the United States will have an eating disorder in their lifetime; 95% of them are between ages 12 and 25, according to Johns Hopkins All Children’s Hospital. The hospital adds that eating disorders pose the highest risk of mortality of any mental health disorder. And it has become easier than ever for minors to get pills that are sold online or on drugstore shelves. All dietary supplements, which include those for weight loss, accounted for nearly 35% of the over-the-counter health products industry in 2021, according to Vision Research Reports, a market research firm.

Dietary supplements, which encompass a broad range of vitamins, herbs, and minerals, are and don’t undergo scientific and safety testing as prescription drugs and over-the-counter medicines do.

Public health advocates want to keep weight loss products — with ads that may promise to and pill names like Slim Sense — away from young people, particularly girls, since some research has linked some products to eating disorders. A , which followed more than 10,000 women ages 14-36 over 15 years, found that “those who used diet pills had more than 5 times higher adjusted odds of receiving an eating disorder diagnosis from a health care provider within 1 to 3 years than those who did not.”

Many pills have been found tainted with banned and dangerous ingredients that may cause cancer, heart attacks, strokes, and other ailments. For example, the FDA Slim Sense by Dr. Reade because it contains lorcaserin, which has been found to cause psychiatric disturbances and impairments in attention or memory. The FDA ordered it discontinued and the company couldn’t be reached for comment.

“Unscrupulous manufacturers are willing to take risks with consumers’ health — and they are lacing their products with illegal pharmaceuticals, banned pharmaceuticals, steroids, excessive stimulants, even experimental stimulants,” said Bryn Austin, founding director of the Strategic Training Initiative for the Prevention of Eating Disorders, or STRIPED, which supports the restrictions. “Consumers have no idea that this is what’s in these types of products.”

STRIPED is a public health initiative based at the Harvard T.H. Chan School of Public Health and Boston Children’s Hospital.

An industry trade group, the Natural Products Association, disputes that diet pills cause eating disorders, citing the lack of consumer complaints to the FDA of adverse events from their members’ products. “According to FDA data, there is no association between the two,” said Kyle Turk, the association’s director of government affairs.

The association contends that its members adhere to safe manufacturing processes, random product testing, and appropriate marketing guidelines. Representatives also worry that if minors can’t buy supplements over the counter, on the black market and undermine the integrity of the industry. Under the bills, minors purchasing weight loss products must show identification along with a prescription.

Not all business groups oppose the ban. The American Herbal Products Association, a trade group representing dietary supplement manufacturers and retailers, dropped its opposition to California’s bill once it was amended to remove ingredient categories that are found in non-diet supplements and vitamins, according to Robert Marriott, director of regulatory affairs.

Children’s advocates have found worrisome trends among young people who envision their ideal body type based on what they see on social media. According to a study , a nonprofit that seeks to stop harmful marketing practices targeting children, kids as young as 9 were found to be following three or more eating disorder accounts on Instagram, while the median age was 19. The authors called it a “.”

Meta, which owns Instagram and Facebook, said the report lacks nuance, such as recognizing the human need to share life’s difficult moments. The company argues that blanket censorship isn’t the answer. “Experts and safety organizations have told us it’s important to strike a balance and allow people to share their personal stories while removing any content that encourages or promotes eating disorders,” said Liza Crenshaw, a Meta spokesperson, in an email.

Dr. Jason Nagata, a pediatrician who cares for children and young adults with life-threatening eating disorders, believes that easy access to diet pills contributes to his patients’ conditions at UCSF Benioff Children’s Hospital in San Francisco. That was the case for one of his patients, an emaciated 11-year-old girl.

“She had basically entered a starvation state because she was not getting enough nutrition,” said Nagata, who provided supporting testimony for the California bill. “She was taking these pills and using other kinds of extreme behaviors to lose weight.”

Nagata said the number of patients he sees with eating disorders has tripled since the pandemic began. They are desperate to get diet pills, some with modest results. “We’ve had patients who have been so dependent on these products that they will be hospitalized and they’re still ordering these products on Amazon,” he said.

Public health advocates turned to state legislatures in response to the federal government’s limited authority to regulate diet pills. Under a 1994 federal law known as the , the FDA “cannot step in until after there is a clear issue of harm to consumers,” said Austin.

No match for the supplement industry’s on Capitol Hill, public health advocates shifted to a state-by-state approach.

There is, however, a push for the FDA to improve oversight of what goes into diet pills. U.S. Sen. Dick Durbin of Illinois in April introduced that would require dietary supplement manufacturers to register their products — along with the ingredients — with the regulator.

Proponents say the change is needed because manufacturers have been known to include dangerous ingredients. C. Michael White of the University of Connecticut’s School of Pharmacy found in a review of a health fraud database.

A few ingredients have been banned, including sibutramine, a stimulant. “It was a very commonly used weight loss supplement that ended up being removed from the U.S. market because of its elevated risk of causing things like heart attacks, strokes, and arrhythmias,” White said.

Another ingredient was phenolphthalein, which was used in laxatives until it was identified as a suspected carcinogen and banned in 1999. “To think,” he said, “that that product would still be on the U.S. market is just unconscionable.”

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Allen’s crying may be distressing, but his wide-open mouth allows Calvo to begin the exam. She counts his baby teeth and checks for dental decay.

“Nothing I am going to do will hurt him,” Calvo tells Allen’s mother, Maritza Barron, who is holding her son’s hands.

To some, the 20-month-old toddler may seem far too young for a dental exam. In fact, he’s on the late side, according to .

To stave off a lifetime of dental problems and make sure parents learn how to prevent children’s tooth decay, babies should have their first exam when they get their first tooth, or no later than their 1st birthday, according to from the American Academy of Pediatric Dentistry.

However, many dentists are uncomfortable treating babies, and that has created a significant gap in dental care for infants and toddlers of all backgrounds, experts say. The shortfall is hard to quantify because professional organizations, such as the American Dental Association, do not survey their members on whether they care for infants.

“People think that children are afraid of dentists, but really it’s that dentists are afraid of children,” said Pamela Alston, who is a dentist and dental director of the Oakland-based Eastmont Wellness Center, a publicly funded clinic that is part of the county-run Alameda Health System.

Hoping to narrow the gap in care, the public health agencies of San Francisco and Alameda counties are launching pilot programs to train dentists to treat babies. About 70 dentists will learn over the next three years how to coax infants into cooperating and help parents guard against tooth decay. The first training session in Alameda County is scheduled for early November; San Francisco will begin its training in January. The American Dental Association was not aware of any similar programs in other states.

The guidelines calling for earlier dental visits stemmed from a growing awareness that cavity-causing bacteria , through shared utensils, for example. Giving babies bottles of fruit juice or sugar water also can cause cavities. Decay in baby teeth has been linked to adult tooth decay.

“By the time children are age 3, they are often so far down the road that prevention is no longer an option,” said Ray Stewart, a pediatric dental professor at UCSF, who has treated infants for more than 15 years and is among the professionals enlisted by Alameda and San Francisco to train the dentists.

Dentists don’t regard exams of very young children as a means of boosting their income, said Alicia Malaby, spokeswoman for the California Dental Association. “Denti-Cal reimbursements are below actual costs for many procedures,” she said. Rather, they want to help “improve community health outcomes.”

Low-income children, who are and have to care than their affluent peers, present the greatest need for early oral exams, dental professionals say.

A portion of the revenue from California’s new tobacco tax will be earmarked to help very young children from low-income families get the dental care they need. The money will be used to give dentists a 40 percent increase on top of the standard reimbursement for services to Denti-Cal patients, including oral exams of children age 3 and under. Denti-Cal provides dental care to beneficiaries of Medi-Cal, California’s version of Medicaid.

Alameda County will offer dentists an extra $20, on top of that statewide increase for appointments with Denti-Cal-covered children that include a thorough exam of the baby’s mouth, a fluoride varnish if needed, a talk with parents about prevention and a demonstration of how to brush their baby’s teeth.

The Alameda and San Francisco training programs, funded by grants from Medi-Cal, could be replicated throughout California if they are successful, according to the Department of Health Care Services.

Maritza Barron came to UCSF after her own dentist — despite the best of intentions — was unable to examine her baby’s mouth. “He tried to say ‘open up’ to him but he wouldn’t do it,” Barron said of the failed attempt, which left her son in tears.

Alston, the Oakland dentist, once faced similar challenges treating very young children, but she has since undergone a transformation. She blames dentists’ wariness of young patients on a lack of experience. When she graduated from dental school in 1982, she said, she had no training that prepared her to work with children younger than 6.

“I didn’t feel like I could manage their behavior,” Alston said.

Over time, however, it became increasingly clear to her that she wasn’t seeing children early enough.

Almost all of the kids who came to her for their first dental visit at age 6 had mouths riddled with tooth decay, Alston said. She had to refer them to specialists for treatment that required sedation. She kept lowering the minimum age for a first visit in her practice, then left it at age 3 for a long time.

But even 3-year-olds were coming in with cavities. Ultimately, she learned how to treat infants and toddlers through a program run by Alameda County’s public health department — not unlike the training to be offered by the new pilot programs.

Today, Alston is passionate about treating very young children and has lined up pediatricians to refer infants to her. And she has revised her guidance on when kids should get their first oral exam, advising parents to bring their children in when their first tooth starts to erupt.

People think that children are afraid of dentists, but really it’s that dentists are afraid of children.

Pamela Alston, Eastmont Wellness Center

She also trains dental students to examine infants. An important trick she teaches them is how to avoid being bitten: “Put your finger behind the last tooth!”

Communicating directly with children during dental exams can help reduce their stress, saod both Alston and Stewart, the UCSF dental professor.

At a recent visit to UCSF’s Pediatric Dentistry Faculty Clinic, 18-month-old Sebastian King scrutinized the dental mirror Stewart handed to him.

“That’s what I’m going to put in your mouth to look at your teeth!” Stewart told him exuberantly.

He asked the young boy to show him where his mouth was. Sebastian smiled with delight as Stewart handed him a blue exam glove he’d blown up into a balloon, and the young boy remained calm throughout the exam.

Helping parents understand their role is also critical, dentists say.

In addition to advising parents not to share eating utensils with their children, Stewart urges them not to let their kids fall asleep with a bottle of milk and to limit their consumption of fruit juice. He also says they should wipe their infants’ gums and teeth with a cloth after feeding them to remove residue that can cause cavities.

That’s the message Calvo, the dental resident, gave to Barron, whose baby sat happily on his mother’s lap after his exam. The boy had cavities because he had been falling asleep with his bottle.

Barron said she recognized that weaning Allen from the bottle at night would be a challenge.

But “it’s really logical,” she told Calvo, adding that she was determined to give it a try.

This story was produced by , which publishes , an editorially independent service of the .

KHN’s coverage of children’s health care issues is supported in part by a grant from .

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Strolling through the clinic, one of the first of its kind in the nation, founder Dr. David Smith points to a large collage that decorates a wall of an exam room affectionately referred to as the Psychedelic Wall of Fame. The 1967 relic shows a kaleidoscope of images of Jefferson Airplane and other legendary counterculture bands, floating in a dreamscape of creatures, nude goddesses, peace symbols and large loopy letters.

“That was made by a woman who had just taken LSD. She stayed here for a very long time and put all that up. It lasted as long as her LSD trip,” Smith said moving on to what was once called the “bad trip” room, where clinic staff would talk down clients during acid trips gone awry.

Fundamentally, Smith and others say, the organization has remained true to its counterculture roots, still offering free care in a deliberately nonjudgmental atmosphere.

But it is also drastically different: It is now the Haight Ashbury Free Clinics — plural — and part of a multi-million-dollar conglomerate with the decidedly un-hippie name ofÌý.

All told, HealthRIGHT 360 serves approximately 40,000 patients each year in a wide range of programs, including “reentry” services to formerly incarcerated adults and teens, residential and outpatient drug treatment, mental health care and medical and dental care. In 2014, it purchased a 50,000 square foot building at 1563 Mission Street in San Francisco as additional space to offer all of these services under one roof. The organization also serves patients inÌýo andÌýÌýcounties.

It’s been a long journey from Smith’s early days running a standalone clinic.

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When the clinic first opened, it operated 24 hours a day with an army of volunteer physicians from the University of California-San Francisco and Stanford. The one paid staffer was a nurse. The first year’s budget was her salary: $25,000.

It had a “guerilla” pharmacy, Smith said. Pharmaceutical representatives would load up their trunks with medication samples and drop them off at the clinic, where a team of UCSF volunteer pharmacists bottled up the medication and shelved it, according to Smith, who noted wryly that the illegal activity long ago reached its “statute of limitations.”

“Our first exam table was my kitchen table,” he recalls. Decisions were made by consensus, and even the janitor weighed in, Smith said.

Benefit rock concerts organized by the iconic music promoter Bill Graham, featuring performances by George Harrison and Janis Joplin, helped the clinic stay afloat financially.

Smith remembers when Joplin overdosed on heroin, and the clinic rushed over an “overdose team” armed with the anti-opioid medication naloxone: “We zipped out there and reversed her overdose,” recalls Smith.

As Smith tells it, many Vietnam veterans returned from the war in the early 1970s addicted to heroin. They felt ostracized by what was then called the Veterans Administration and headed to Haight Ashbury and its clinic, which by then offered comprehensive medical cares and a drug detox program.

The influx of veterans led to federal grants from Special Action Office on Drug Abuse Prevention. “That began the government funding era in the 1970s and ensured our survival,” said Smith.

In the 1980s, a young woman named Vitka Eisen learned firsthand the value of the personal attention the clinic offered. She came to the Haight Ashbury clinic struggling with heroin addiction. “I went there for detox at least nine times,” she said. “I never felt shamed or judged. They always acted like they were glad to see me.”

Her trust in the staff led her to kick her heroin habit and return to school, where she eventually earned a doctorate in education from Harvard.

Eisen took the helm as CEO of HealthRIGHT360 in 2010.

The clinics’ business model began to change dramatically in 2007, when it added another site at 1735 Mission Street, San Francisco.

But by 2011, like many recession-era nonprofits, the clinics were deeply in debt, Smith said. So they merged with the renowned San Francisco-based addiction and mental health treatment program, Walden House, which wanted to offer comprehensive medical care to its patients. The two nonprofits merged, and adopted the name HealthRIGHT360.

By joining forces in 2011, Walden House and the Haight Ashbury Free Clinics were able to weather the extraordinary financial expense of shifting their organizations to electronic health records, a requirement of the Affordable Care Act, said Eisen.

With the system in place, she said, it’s easy enough to train and add on new providers as HealthRight360 has expanded. The merger also allowed the Haight Ashbury Free Clinics to erase its debt in a year.

Between then and its latest merger in July with Prototypes, a Southern California women’s drug treatment center, HealthRIGHT360 has acquired five other community clinics in Northern California and offers treatment at 40 sites up and down the state, according to its former Vice President of Development Michelle Hudson.

Ben Avey, assistant director for external affairs at the California Primary Care Association, said such mergers aren’t new, but they have accelerated under the now-imperiled ACA.

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At the individual clinics that comprise health systems like HealthRIGHT360, “they speak your language, know your culture, understand the situation you’re coming from,” Avey added.

As CEO, Eisen led the consolidation that streamlined HealthRIGHT 360. “We have one board, one human resources department, one finance department, one payroll department and one executive.” The annual revenue, said Eisen, is $110 million. Medi-Cal, the city, county, state and federal governments reimburse HealthRIGHT 360 for providing patient services, as do commercial health insurers.

But ties to the early days remain. The early treatment of concertgoers evolved into San Francisco-based Rock Medicine, which is now part of HealthRight360 and sets up on site at rock concerts, circuses and fairs in the San Francisco Bay Area and Los Angeles garnering $1,038,000 annually from the venues.

And the non-judgmental reception by the Haight Ashbury Free Clinics’ staff continues to this day, according to 61-year-old David Smith, (no relation to the clinic founder) who has been coming to the clinic since the 1980s and has always felt welcomed and accepted.

This was true even when Smith was homeless in the early 2000s.

“It didn’t matter if I was dirty,” he says. “I didn’t have to feel like I couldn’t come in here because I wasn’t in the proper state of cleanliness, which was unfortunately the case for a quite bit of the time.”

This story was produced by , which publishes , an editorially independent service of the .

This <a target="_blank" href="/public-health/from-its-counterculture-roots-haight-ashbury-free-clinic-morphs-into-health-care-conglomerate/">article</a&gt; first appeared on <a target="_blank" href="">Â鶹ŮÓÅ Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">